Nokea
For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
- D. Obtain the first unit of packed RBCS from the blood bank.
- E. Start an IV bolus of lactated Ringers solution.
Correct Answer: A,B,D
Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.
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The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
- B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8
- D. A client who received a Mantoux test 48 hr ago and has an induration
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care as the INR is subtherapeutic, increasing the risk of clot formation. A therapeutic INR for clients on warfarin is typically between 2-3. Options A, B, and D do not require immediate follow-up care. A potassium level of 3.6 mEq/L is within the normal range. Sodium phosphate for a colonoscopy preparation is appropriate. An induration after a Mantoux test is an expected finding.
Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy?
- C. The hepatitis& immunization should not be obtained until after you finish breastfeeding
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The correct answer is D: You can receive the immunization for influenza at any time during your pregnancy. This statement is correct because the influenza vaccine is recommended for pregnant women at any stage of pregnancy to protect both the mother and the unborn baby. It is safe and effective during pregnancy.
Incorrect choices:
A: The immunization for varicella should be given at least 1 month prior to delivery - This is incorrect because the varicella vaccine is not routinely recommended during pregnancy.
B: You can receive the rubella immunization during the third trimester of pregnancy - This is incorrect because the rubella vaccine is contraindicated during pregnancy.
C: The hepatitis B immunization should not be obtained until after you finish breastfeeding - This is incorrect because the hepatitis B vaccine is recommended during pregnancy to prevent transmission to the baby.
Which of the following laboratory findings should the nurse expect following the transfusion?
- A. Increased platelets
- B. Increased Hct
- C. Decreased Hgb
- D. Decreased WBC count
Correct Answer: B
Rationale: The correct answer is B: Increased Hct. Following a transfusion, the nurse should expect an increase in hematocrit (Hct) levels due to the addition of packed red blood cells. This will result in an increase in the concentration of red blood cells in the blood, leading to a higher Hct value. The other choices are incorrect as: A) Increased platelets are not typically affected by a red blood cell transfusion, C) Decreased Hgb would not be expected as the purpose of the transfusion is to increase hemoglobin levels, and D) Decreased WBC count is unrelated to a red blood cell transfusion.
A charge, nurse is teaching new staff members about factors that increase a client's risk to become violent: Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. A history of being in prison
- B. Male gender
- C. Experiencing delusions
- D. Previous violent behavior
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to engage in violent acts again. Choice A (A history of being in prison) is not as strong of a predictor as it does not specifically address violent behavior. Choice B (Male gender) is a generalization and not always indicative of violent behavior. Choice C (Experiencing delusions) may increase the risk of violence but does not directly predict future violent behavior as strongly as previous violent actions do.
The nurse anticipates the client will likely require-------as evidenced by the client’s---------
- A. temperature
- B. stool test results
- C. respiratory rate
- D. an endoscopy
- E. an antifungal prescription
- F. oxygen via nonrebreather mask
Correct Answer: B,D
Rationale: The correct answers are B (stool test results) and D (an endoscopy). The nurse anticipates the client will likely require a stool test based on gastrointestinal symptoms, such as abdominal pain or blood in stool. Stool test results can help diagnose gastrointestinal issues. Additionally, the nurse may anticipate the need for an endoscopy to further investigate gastrointestinal symptoms, like persistent reflux or difficulty swallowing. Choices A, C, E, and F are less likely as they are not directly related to gastrointestinal issues. Choice E (antifungal prescription) may be relevant in case of fungal infection, but gastrointestinal symptoms would not typically prompt this. Choice F (oxygen via nonrebreather mask) is more related to respiratory issues.